Root cause analysis paper

Root cause analysis paper
Do a root cause analysis (RCA) that looks at the factors, mistakes, or risks that led to the sentinel event (this patient’s outcome). In response to a sentinel event like the one below, healthcare organizations that are accredited by the Joint Commission have to do a root cause analysis (RCA). Once the cause has been found and a plan of action has been made, it is helpful to do a failure mode and effects analysis (FMEA) to make it less likely that a process will fail.

Root cause analysis paper
As a member of the hospital’s healthcare team, you have been chosen to be part of the team that is looking into what happened.
Scenario:

On a Thursday at 3:30 p.m., Mr. B, who is 67 years old, goes to the six-room emergency department (ED) of a rural hospital with sixty beds. His son and a neighbor took him to the hospital. At the moment, Mr. B is moaning and saying that his (L) leg and hip hurt a lot. He says that when he tripped over his dog, he lost his balance and fell.

Mr. B was taken to the triage room, where his vital signs were recorded as B/P 120/80, HR-88 (normal), T-98.6, R-32, and 175 pounds. Mr. B says he has never had allergies or fallen before. He says, “I have a lot of pain in my hip and leg. Nothing like this has ever happened to me before.” On the numerical verbal pain scale, the patient says the pain is a 10 out of 10. He seems to be in a bit of trouble. His (L) leg looks shorter and has edema in the calf, redness, and a limited range of motion (ROM).

After Mr. B’s leg is set, he is given more care and sent from triage to a patient room in the emergency department (ED). Nurse J brings him to the hospital. The nurse who checks Mr. B in finds that he has a history of not being able to handle sugar well and of having prostate cancer. At Mr. B’s last appointment with his primary care doctor, lab tests showed that his cholesterol and lipids were too high.

Root cause analysis paper
For his chronic back pain, Mr. B is taking atorvastatin and oxycodone. After the nurse finishes evaluating Mr. B, Nurse J tells the ED doctor what she found during admission, and the ED doctor then examines Mr. B.

On this day, there are two nurses (one RN and one LPN), one secretary, and one doctor who works in the emergency room. Respiratory therapy is available on-site and when needed. When Mr. B comes in, the ED staff is already taking care of two other people. A 43-year-old woman with a throbbing headache is one of the patients. On a numerical verbal pain scale, the patient says the pain is a four out of ten right now.

The person says she has had migraines in the past. She got treatment, is doing well, and is about to be let go. The second person being looked at is an eight-year-old boy who might have appendicitis. This patient is still waiting for lab results. The ED doctor looked at, evaluated, and cared for both of these patients. They are now waiting for more treatment or orders.

The ED doctor, Dr. T, writes an order for Nurse J to give diazepam 5 mg IVP to Mr. B after he has looked at him. At 4:05 p.m., the drug diazepam is given intravenously (IV). After five minutes, the diazepam doesn’t seem to have done anything to Mr. B, so Dr. T tells Nurse J to give him 2 mg IVP of hydromorphone. At 4:15, the medicine (hydromorphone) is given through an IV. Dr. T is still not happy with Mr. B’s level of sedation after five minutes, so he tells Nurse J to give him another 2 mg of hydromorphone IVP and 5 mg of diazepam IVP.
Root cause analysis paper

The goal of the doctor is for the diazepam to relax the patient’s skeletal muscles. This will help the doctor move Mr. B’s hip and get it in the right place. The hydromorphone IVP was given to stop the pain and make the person sleepy. After looking at the patient’s medical history, Dr. T notices that Mr. B’s weight and the fact that he takes oxycodone every day seem to make it harder to put him to sleep.

At 4:25, the patient seems to be put to sleep, and his (L) hip is successfully set back into place. The procedure seems to have gone well, and the patient is still asleep. He is not getting any extra oxygen right now. At 4:30 p.m., the procedure is over, and Mr. B is resting without any signs of pain or distress. At this time, the ED gets a call from emergency dispatch telling them that paramedics from the emergency rescue unit are on their way with a 75-year-old patient who is having trouble breathing.

Nurse J gives Mr. B a pulse oximeter and a blood pressure machine that is set to check his blood pressure every five minutes. Nurse J leaves his room at this point. The nurse lets Mr. B’s son sit with him while his blood pressure is being checked. Mr. B’s blood pressure is 110/62 and his oxygen level is 92% at 4:35. He is still not getting extra oxygen, and neither his ECG nor his breathing are being watched.

Root cause analysis paper
The emergency transport patient has been taken care of by Nurse J and the LPN who was on duty. They are also getting ready to send the other two patients home. In the meantime, the ED lobby is getting crowded with new patients. At this time, Mr. B’s O2 saturation alarm sounds and shows “low O2 saturation” (it is currently showing a sat of 85%). The LPN briefly goes into Mr. B’s room, resets the alarm, and takes the B/P reading again.

Nurse J is now giving the patient in respiratory distress emergency care, which includes assessing, evaluating, and ordering respiratory treatments, CXR, labs, etc.

At 4:43, Mr. B’s son comes out of the room and tells the nurse that the “monitor is alarming.” When Nurse J walks into the room, Mr. B’s blood pressure is 58/30 and his oxygen saturation is 79%, according to the blood pressure machine. The person is not breathing, and there is no pulse that can be felt.

The son is taken to the waiting room after a STAT CODE is called. The code team arrives and starts trying to save the person’s life. When Mr. B is hooked up to the heart monitor, it shows that his heart is in ventricular fibrillation. The RN starts CPR right away, and Mr. B is given a breathing tube. He is given reversal agents, IV fluids, and vasopressors, and the defibrillator is turned off. After 30 minutes of treatment, the ECG goes back to a normal sinus rhythm with a pulse and a B/P of 110/70.

The patient can’t breathe on his own, so he needs the ventilator to do it for him. The person’s pupils are large and fixed. He doesn’t move on his own and doesn’t react to painful things. The family asks for air transport, and the patient is moved to a tertiary facility for more advanced care.

Root cause analysis paper
Seven days later, the hospital that took care of Mr. B told the rural hospital that EEGs showed that he was brain dead. The family asked that Mr. B’s life support be turned off, and he died soon after.

More information: The hospital where Mr. B. was first seen and treated had a moderate sedation/analgesia (“conscious sedation”) policy that requires the patient to stay on continuous B/P, ECG, and pulse oximeter during the procedure and until the patient meets specific discharge criteria (i.e., fully awake, VSS, no N/V, and able to urinate). All doctors and nurses who do moderate sedation must first pass the hospital’s training module on moderate sedation. The training module covers how to choose a drug and how much of it is safe to give.

On the day of the incident, there was extra (backup) staff on hand. The module on moderate sedation had been finished by Nurse J. Nurse J was certified in ACLS and had worked as a critical care nurse for a long time. The manager’s previous annual clinical reviews of Nurse J showed that she was “meeting requirements.” Nurse J had never been careless about her patients before. On this day, there was enough equipment in the ED and it was all working.

Root cause analysis paper Task:

A. Do a root cause analysis (RCA) that looks at the factors, mistakes, and/or risks that led to the sentinel event (the outcome for this patient).

B. Talk about a plan for improving the process that would make it less likely that the scenario’s outcome would happen again.

1. Talk about a theory of change that could be used to put the process improvement plan made in B into action.

C. Use a failure mode and effects analysis (FMEA) to estimate how likely it is that the plan you suggest for improving the process won’t fail.

1. Figure out who will be part of the FMEA from the multidisciplinary team.

2. Talk about the steps for getting ready for the FMEA.

3. Apply the three steps of the FMEA (severity, occurrence, and detection) to the process improvement plan made in part B.

4. Explain how you would test the interventions in the process improvement plan from Part B to improve care in a similar situation.

Note: You don’t have to do the whole FMEA, but you should explain each step and how you would use it to improve your process.

D. Talk about how a professional nurse can be a leader in promoting quality care and influencing activities to improve quality.

E. When you use sources to back up ideas and parts of a paper or project, you should give credit to the source for any content that you quote, paraphrase, or summarize. Acknowledgment of sources includes a citation in the text that says exactly where in the submission the source is used, as well as a reference that includes:

• Writer

• Date

• Title

• Where to find information (e.g., publisher, journal, or website URL)

Note: APA-style citations are recommended, but not required, for this task. Evaluators will give feedback on how well sources are cited, but not on how well they follow APA or another citation style.

Note: No more than 30% of a paper can be directly quoted or closely paraphrased from outside sources, even if they are properly cited.

Please include all of the following:
Method of Evaluating
In this Evaluation, a rubric is used.

The candidate gives a clear, well-thought-out answer.

The candidate does a proper root cause analysis (RCA) with a lot of detail, taking into account the factors, mistakes, and/or risks that led to the sentinel event (the outcome of this patient).

The candidate gives a clear, detailed explanation of a process improvement plan that would make it less likely that the scenario’s outcome would happen again.

The candidate gives a clear and detailed explanation of a change theory that could be used to carry out the plan for improving the process made in B.

The candidate uses a failure mode and effects analysis, which is backed up by a lot of evidence, to estimate how likely it is that the plan for improving the process won’t fail.

The candidate knows exactly which members of the multidisciplinary team will be part of the FMEA.

The candidate explains the steps for getting ready for the FMEA in a clear way and with a lot of detail.

The candidate uses the three steps of the FMEA (severity, occurrence, and detection) in a good way and with a lot of detail in the process improvement plan made in part B.

The candidate gives a clear, well-supported explanation of how they would test the interventions from part B of the process improvement plan to improve care in a similar situation.

The candidate explains in detail and in a logical way how the professional nurse can be a leader in promoting quality care and influencing activities to improve quality.

The candidate gives the source for all content that is quoted, paraphrased, or summed up. Source information seems to include accurate and complete acknowledgments of the author, date, title, and location of the information (e.g., publisher, journal, or website URL), as well as correct in-text citations. This level is also right if there is no evidence of content that has been quoted, paraphrased, or summed up, and the instructions don’t require it.

Related Posts:

(Visited 9 times, 1 visits today)

Warning: Use of undefined constant php - assumed 'php' (this will throw an Error in a future version of PHP) in /home/prowritershub/web/originalnursingpapers.com/public_html/wp-content/themes/freelance/single.php on line 55